Limited coverage criteria – cyclosporine

 

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Generic name	cyclosporine
Strength and form	10 mg, 25 mg, 50 mg, 100 mg capsule 100 mg/mL / solution

Special Authority criteria

Approval period

For the treatment of: 1. Diagnosis of rheumatoid arthritis AND when a Special Authority request is submitted by a rheumatologist OR 2. Severe ocular inflammatory disease AND when a Special Authority request is submitted by an ophthalmologist or rheumatologist OR 3. Extensive psoriasis involving at least 25% of body surface or having psoriasis area and severity index of at least 12 AND when a Special Authority request is submitted by a dermatologist MORE Treatment failure of the following: Topical therapy with corticosteroids; and Ultraviolet-B light or oral or topical methoxsalen plus ultraviolet-A light OR 4. Psoriasis of the palms and/or soles severe enough to interfere with daily living or work  MORE Treatment failure on topical corticosteroids AND when a Special Authority request is submitted by a dermatologist OR 5. Nephrotic syndrome AND when a Special Authority request is submitted by a nephrologist.

Indefinite

Practitioner exemptions

• Prescriptions for oral cyclosporine written by an exempted prescriber are eligible for PharmaCare coverage without submission of a Special Authority request. No Special Authority record will be created on the PharmaNet system
• For any patient who does not meet the Limited Coverage criteria, a practitioner with an exemption is required to do one of the following:
  1. Write on the prescription “Submit as zero cost to PharmaCare”, to indicate to the pharmacist that the prescription is not to be covered by PharmaCare; OR
  2. Apply for exceptional PharmaCare coverage by submitting a Special Authority request with full documentation (via fax to 1 800-609-4884). Special Authority requests are subject to review by PharmaCare and will not be covered automatically. If PharmaCare coverage is denied the practitioner must write on the prescription “Submit as zero cost to PharmaCare”

Special notes

• Special Authority requests for the treatment of moderate to severe atopic dermatitis will be considered on a case-by-case basis when coverage is requested by a dermatologist, allergist, or clinical immunologist

Special Authority request form(s)

• Log in to eForms
• HLTH 5328 – General Special Authority request (PDF, 656KB)